Healthcare Provider Details

I. General information

NPI: 1760929574
Provider Name (Legal Business Name): JACY II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1326 E RIPLEY ST
LITCHFIELD MN
55355-4525
US

IV. Provider business mailing address

1326 E RIPLEY ST
LITCHFIELD MN
55355-4525
US

V. Phone/Fax

Practice location:
  • Phone: 320-593-0440
  • Fax: 320-593-0442
Mailing address:
  • Phone: 320-593-0440
  • Fax: 320-593-0442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number010872752
License Number StateMN

VIII. Authorized Official

Name: MATTIE J MAUMGARATNER
Title or Position: ADMINISTRATOR
Credential:
Phone: 320-593-0440